MANCHESTER - A long-awaited report on the city's emergency ambulance provider, American Medical Response, finds little evidence of overbilling but confirms many of the complaints lodged against the company over the past year.

The report, presented to the Committee on Accounts, Enrollment and Revenue Administration Monday by Auditor Kevin Buckley, describes several practices that have upset patients and aldermen, but that are not violations of its contract with the city Fire Department.

These practices include sending patients bills for thousands of dollars for a single ambulance trip, while the amount actually owed by the patient is still being worked out, and then having those bills sent to a collections department.

"No actual overcharge errors were noted; however, the billing seems to be confusing for most patients," Buckley states in the report. "This confusion makes it appear to the patients that they are being overcharged."

The problem is compounded by the fact that AMR is expensive compared to other ambulance companies in the state, with average per-trip rates at close to $2,000. While the contract with the fire department states that the company can charge no more than 35 percent above the Medicare reimbursement rate - around $600 - for emergency trips, the company seeks a higher rate from insured patients.

In addition, patients, once they are taken to the hospital, often end up being transported by AMR for non-emergency trips to other facilities - and are billed at its standard rates. The problem, according to Buckley, is that the hospitals often don't indicate to patients that there are other cheaper ambulance services available. Anthem and AMR

One reason city residents have been so closely involved in billing issues with AMR is that the city's largest insurer, Anthem Blue Cross Blue Shield, does not have a provider agreement with the company. Anthem administers the city of Manchester's health plan, which includes hundreds of employees.

Anthem had been reimbursing patients directly for bills from AMR. At the beginning of 2012, however, a new state law, HB 31, went into effect requiring insurers to pay out-of-network ambulance companies directly. Since then, Anthem has been paying its own standard rate for ambulance reimbursements, leaving patients in some cases to cover the balance.

Anthem representative Amy Winning told the aldermen that HB 31 created less incentive for out-of-network ambulance companies to enter agreements. She said Anthem has attempted to reach an agreement with AMR, but that the company had not responded to it most recent request.

An AMR representative is quoted in Buckley's report saying, "AMR has reached out to Anthem on several occasions and tried to reach an amicable agreement. Like all emergency ambulance providers in New Hampshire, AMR is not opposed to entering into an agreement... provided (it ) satisfactorily compensates for the high cost of readiness associated with providing emergency ambulance coverage and response."

AMR had acknowledged earlier this year overbilling 323 patients; it has since paid refunds or corrected the bills.

Contract up for renewal

Buckley found that of 60 ambulance trips he tested as a sample, one was overbilled and not discovered by AMR. The company makes about 18,000 transports in the city per year.

The anecdotal evidence, however, appeared to weigh more heavily for the aldermen.

Alderman Patrick Arnold called the practice of quickly referring bills to collections the most "troubling" aspect of the company's behavior.

The report comes as the aldermen are weighing whether to renew AMR's contract, which expires at the end of December. Fire Chief James Burkush has proposed a one-year renewal while the department explores operating its own emergency ambulance service, as it had more than two decades ago.

Alderman Pat Long said it was unlikely that he would support renewing the contract if the "unacceptable" continued. "If so, I'll lean toward getting another provider or having the city pick it up itself," he said.

The full Board of Mayor and Aldermen is expected act on two committee recommendations at its meeting Tuesday. One urges Anthem and AMR to come to a service agreement and calls on the city's legislative delegation to come up with a bill that would require such agreements.